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OUTREACH PEDIATRIC THERAPY, INC.

Consent for Evaluation and to Provide Treatment


I authorize the staff of Outreach Pediatric Therapy to:

1. Administer and perform evaluations to determine the need for therapy services 2. Administer therapy services recommended by evaluating therapist

________________________ Parent Signature _______________________ Childs Name (Print)

___________________________________ Relationship ____________________________________ Date

Outreach Pediatric Therapy, Inc. All rights reserved

Revised: 12/27/11

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